In Shadow Of Artificial Hearts Lies Ethical Dilemmas

April 7, 1985|By Richard A. Knox and Richard Saltus, BOSTON GLOBE

Only last year it seemed that the choice for thousands of Americans with failing hearts was grim. They could hope to gain entry into one of a handful of U.S. heart transplant programs, and then hope a suitably matched donor heart turned up in time. Or they could prepare to die.

In the spring of 1985, however, the horizon is crowded with new technologies designed to stave off cardiac death.

Heart transplants quickly are becoming routine, even in some community hospitals. Human trials of artificial hearts are under way, as permanent replacements for the natural organ and as ''bridges'' to heart transplants. Doctors also are trying out new generations of implantable pumps that assist failing hearts rather than replace them.

The best estimates put the number of potential U.S. candidates for all these new approaches at about 50,000 a year.

The result of all this ferment, say a variety of observers, is likely to be mixed. On one hand, this pluralistic approach may foster more rapid development of mechanical pumps to assist or replace failing hearts. But the proliferation of devices likely will lead to a bewildering array of options and ethical dilemmas.

What worries some doctors is the lack of any central agency for evaluating these new procedures and recommending how they should be used.

''The process by which we make this kind of policy decision in the United States is troublesome,'' said Stanford University's Dr. John Bunker, who co-wrote a study of the artificial heart for the congressional Office of Technology Assessment. ''We really don't make decisions. We just do things.'' Some dilemmas already have emerged. Others are not at all remote. Consider the following hypothetical problems that could arise in the use of procedures that already are under way:

-- A 48-year-old man is rolled into a hospital emergency room with a heart attack so massive that no medicines can keep his heart going. Doctors install a new artificial device designed to augment his own heart's pumping capacity. They have two hopes in mind: either his heart will recover with rest or a suitably matched human donor heart will turn up before the patient acquires complications that will disqualify him for a heart transplant.

But donor hearts are in short supply, with 30 U.S. heart transplant centers competing for fewer than 450 hearts that are available each year. The man's ''temporary'' heart-assist pump, which does not permit him to leave the hospital, instead becomes an indefinite medical experiment.

-- A middle-aged woman undergoes acute rejection of her transplanted heart. Surgeons implant a prototype artificial heart to act as a ''bridge'' to a second heart transplant.

The success rate of retransplants, however, is less than first heart transplants. At Stanford, for example, there are only six survivors among 26 recipients of second transplants. Because more and more terminally ill heart patients are piling up on transplant waiting lists, some question whether the organs should go to people who haven't received a transplant yet.

-- A 56-year-old man receives a permanently implanted artificial heart. But surgeons at several nearby heart transplant centers raise a new ethical question. Should this man, only a year older than the age cutoff of most heart transplant programs, have received a heart transplant instead? His chances of surviving a year are up to 80 percent with a human heart transplant, with a far better quality of life.

This situation will arise more often, because some transplant centers now are stretching the age limits and permitting some patients with other diseases, such as diabetes, to become transplant candidates.

In fact, 58-year-old Murray Haydon of Louisville, the world's third recipient of the permanently implanted Jarvik-7 artificial heart, may be just such a case. His doctors at Humana Hospital Audubon in Louisville note that Haydon was rejected as a heart transplant candidate by one center, but some think he might have been accepted elsewhere.

''I wondered why Haydon didn't get a heart transplant,'' said Roger Evans of Battelle Human Affairs Research Institute in Seattle, who has conducted a $1.5 million federal study on heart transplants. ''The whole thing is getting a bit muddled as to which patients should be getting which type of treatment.''

The situation is a confluence of two major trends:

Heart transplants, launched in this country 17 years ago, are booming, as a new anti-rejection drug has improved survival rates and convinced surgeons around the country that the technology has arrived to make the procedure more successful.

The other strand is the nation's 22-year effort to develop an implantable artificial heart and other mechanical systems to replace or assist failing hearts. Though not mature, that program has reached a burgeoning adolescence; many believe that, in its multiple guises, the artificial heart is ready for widespread human trials.